WEAR Application Name on Account First Last Mailing Address Date of birth Age Account Number Applicants Social Security Number Service Address (if different from mailing address) Telephone number Wages and or Income from Self Employment Public Assistance SSI/SSA All other income Attach proof of income for the past 60 days for all members of your household. Bank statements are not acceptable.Max. file size: 75 MB.Zero Income Statement If any adult member of your household has a zero income, complete this section and provide 60 days of checking/savings account statements. If income is zero, please explain how bills are paid. Signature and Date Please List all people in your household. Include social security numbers for household members over 18 and NOT on this account.This is a legal document. Please read and intial.1 I hereby authorize the release of information regarding my utility bills, past present and future, as well as authorize the release of information necessary to verify any o the statements or representations herein.2 I hearby authorize LMUD, its agents and assigns to have access to and examine all employment, income, utility and any and all other records deemed to be useful and or pertinent to analyzing my application for WEAR3 I understand that for the purpose of this application, "household" is defined as (a) one person living alone; (b) a single family, (c)two or more families living together; (d) any other group of related or non-related person who are sharing living arrangements.4 I certify under penalty of perjury, that all information is true and correct to the best of my knowledge. I understand that falsification of information of this application will result in my becoming ineligible for WEAR and may result in the reversal of WEAR credits applied to my account and , if that occurs, I shall become immediately responsible for all amounts incurred for electrical service, fees, penalties and other charges.5 I understand that my account muse be current to apply for WEAR. I further understand that if my account receives penalties and/or is disconnected for non-pay, I will be removed from the program.6 I understand that if there is an address change, I must re-apply.7 I understand that I must re-apply yearly. LMUD will not contact me when my application expires.Declaration and Signature and Date By typing my name, I declare that the facts stated herein are true and acknowledge that any misrepresentations or fraudulent statements may disqualify me from any assistance through this program. I understand that my account must be current before my application will be considered for approval and before any assistance can be provided. I also acknowledge that it is my responsibility to notify LMUD if any circumstances change which would affect my eligibility for assistance under this program.
